Harlinde Peperstraete

Implementation of a structured information transfer checklist improves postoperative data transfer after congenital cardiac surgery

BACKGROUND During one hospital stay, a patient can be cared for by five different units. With patient transfer from one unit to another, it is of prime importance to convey a complete picture of the patients situation to minimise the risk of medical errors and to provide optimal patient care. OBJECTIVE(S) This study was designed to test the hypothesis that the implementation of a standardised checklist used during verbal patient handover could improve postoperative data transfer after congenital cardiac surgery. DESIGN Prospective, pre/postinterventional clinical study. SETTING Cardiac centre of a university hospital. PATIENTS Forty-eight patients younger than 16 years undergoing heart surgery. INTERVENTIONS A standardised checklist was developed containing all data that, according to the investigators, should be communicated during the handover of a paediatric cardiac surgery patient from the operating room to the ICU. MAIN OUTCOME MEASURES Data transfer during the postoperative handover before and after implementation of the checklist was evaluated. Duration of handover, number of interruptions, number of irrelevant data and number of confusing pieces of information were noted. Assessment of the handover process by ICU medical and nursing staff was quantified. RESULTS After implementation of the information transfer checklist, the overall data transfer increased from 48 to 73% (P < 0.001). The duration of data transfer decreased from a median (range) of 6 (2 to 16) to 4 min (2 to 19) (P = 0.04). The overall handover assessment by the intensive care nursing staff improved significantly after implementation of the checklist. CONCLUSION Implementation of an information transfer checklist in postoperative paediatric cardiac surgery patients resulted in a more complete transfer of information, with a decrease in the handover duration.

Cold histidine-tryptophan-ketoglutarate solution and repeated oxygenated warm blood cardioplegia in neonates with arterial switch operation.

BACKGROUND The present study aimed to compare myocardial protection, as assessed by cardiac troponin-I release, and short-term outcomes between two groups of neonates undergoing the arterial switch operation (ASO) with either Custodiol cardioplegia (Custodiol HTK, Köhler Chemie GmbH, Bensheim, Germany) or repeated oxygenated warm blood cardioplegia. METHODS A total of 218 neonates were enrolled retrospectively from February 2007 through February 2011. All analyses were stratified on the type of procedure (ASO±ventricular septal defect closure ± aortic arch repair). Troponin concentrations within the first week of surgery were analyzed using mixed models for repeated measurements. To counteract the confounding effect of the coronary anatomy, a sensitivity analysis was conducted after 1:1 matching. RESULTS Overall 30 patients had Custodiol cardioplegia, and 188 had warm blood cardioplegia. High-risk coronary anatomy (single right coronary artery giving rise to the left, intramural course) was associated with higher troponin concentrations and a higher 30-day mortality rate postoperatively, and was more prevalent in the Custodiol group when compared with the warm blood cardioplegia group. Postoperative troponin concentrations were higher in the Custodiol group both before (p<0.001) and after matching on the coronary anatomy (p=0.03). The 30-day mortality rate was higher in the Custodiol group, 10% versus 1.1% (p=0.009), but only a nonsignificant trend was noted after matching. CONCLUSIONS The use of Custodiol cardioplegia in neonates undergoing ASO was associated with a larger troponin release when compared with warm blood cardioplegia, suggesting poor myocardial protection. The difference noted in 30-day mortality was not due to the use of Custodiol.

Acute Kidney Injury in Cardiorenal Syndrome Type 1 Patients: A Systematic Review and Meta-Analysis.

Background: We evaluated the epidemiology and outcome of acute kidney injury (AKI) in patients with cardiorenal syndrome type 1 (CRS-1) and its subgroups: acute heart failure (AHF), acute coronary syndrome (ACS) and after cardiac surgery (CS). Summary: We performed a systematic review and meta-analysis. CRS-1 was defined by AKI (based on RIFLE, AKIN and KDIGO), worsening renal failure (WRF) and renal replacement therapy (RRT). We investigated the three most common clinical causes of CRS-1: AHF, ACS and CS. Out of 332 potential papers, 64 were eligible - with AKI used in 41 studies, WRF in 25 and RRT in 20. The occurrence rate of CRS-1, defined by AKI, WRF and RRT, was 25.4, 22.4 and 2.6%, respectively. AHF patients had a higher occurrence rate of CRS-1 compared to ACS and CS patients (AKI: 47.4 vs. 14.9 vs. 22.1%), but RRT was evenly distributed among the types of acute cardiac disease. AKI was associated with an increased mortality rate (risk ratio = 5.14, 95% CI 3.81-6.94; 24 studies and 35,227 patients), a longer length of stay in the intensive care unit [LOSICU] (median duration = 1.37 days, 95% CI 0.41-2.33; 9 studies and 10,758 patients) and a longer LOS in hospital [LOShosp] (median duration = 3.94 days, 95% CI 1.74-6.15; 8 studies and 35,227 patients). Increasing AKI severity was associated with worse outcomes. The impact of CRS-1 defined by AKI on mortality was greatest in CS patients. RRT had an even greater impact compared to AKI (mortality risk ratio = 9.2, median duration of LOSICU = 10.6 days and that of LOShosp = 20.2 days). Key Messages: Of all included patients, almost one quarter developed AKI and approximately 3% needed RRT. AHF patients experienced the highest occurrence rate of AKI, but the impact on mortality was greatest in CS patients.

A multiscale entropy-based tool for scoring severity of systemic inflammation.

Objective:Early detection and start of appropriate treatment are highly correlated with survival of sepsis and septic shock, but the currently available predictive tools are not sensitive enough to identify patients at risk. Design:Linear (time and frequency domain) and nonlinear (unifractal and multiscale complexity dynamics) measures of beat-to-beat interval variability were analyzed in two mouse models of inflammatory shock to determine if they are sensitive enough to predict outcome. Setting:University research laboratory. Subjects:Blood pressure transmitter-implanted female C57BL/6J mice. Interventions:IV administration of tumor necrosis factor (n = 11) or lipopolysaccharide (n = 14). Measurements and Main Results:Contrary to linear indices of variability, unifractal dynamics, and absolute heart rate or blood pressure, quantification of complex beat-to-beat dynamics using multiscale entropy was able to predict survival outcome starting as early as 40 minutes after induction of inflammatory shock. Based on these results, a new and clinically relevant index of multiscale entropy was developed that scores the key features of a multiscale entropy profile. Contrary to multiscale entropy, multiscale entropy scoring can be followed as a function of time to monitor disease progression with limited loss of information. Conclusions:Analysis of multiscale complexity of beat-to-beat dynamics at high temporal resolution has potential as a sensitive prognostic tool with translational power that can predict survival outcome in systemic inflammatory conditions such as sepsis and septic shock.

Assessment of the optimal operating parameters during extracorporeal CO2 removal with the Abylcap® system

Purpose Lung protective ventilation is recommended in patients with acute respiratory distress syndrome (ARDS) needing mechanical ventilation. This can however be associated with hypercapnia and respiratory acidosis, such that extracorporeal CO2 removal (ECCO2R) can be applied. The aim of this study was to derive optimal operating parameters for the ECCO2R Abylcap® system (Bellco, Italy). Methods We included 4 ARDS patients with a partial arterial oxygen tension over the fraction of inspired oxygen (PaO2/FiO2) lower than 150 mmHg, receiving lung-protective ventilation and treated with the Abylcap® via a double lumen 13.5-Fr dialysis catheter in the femoral vein. Every 24 hours during 5 consecutive days, blood was sampled at the Abylcap® inlet and outlet for different blood flows (QB:200-300-400 mL/min) with 100% O2 gas flow (QG) of 7 L/min, and for different QG (QG: 0.5-1-1.5-3-6-8 L/min) with QB400 mL/min. CO2 and O2 transfer remained constant over 5 days for a fixed QB. Results We found that, for a fixed QG of 7 L/min, CO2 transfer linearly and significantly increased with QB (i.e. from 58 ± 8 to 98 ± 16 mL/min for QB 200 to 400 mL/min). For a fixed QB of 400 mL/min, CO2 transfer non-linearly increased with QG (i.e. from 39 ± 9 to 98 ± 16 mL/min for QG 0.5 to 8 L/min) reaching a plateau at QG of 6 L/min. Conclusions Hence, when using the Abylcap® ECCO2R in the treatment of ARDS patients the O2 flow should be at least 6 L/min while QB should be set at its maximum.

High-dose aprotinin, blood product transfusions, and short-term outcome in neonates and infants: a pediatric cardiac surgery center experience.

Background:  The efficacy of aprotinin, the most popular antifibrinolytic agent in congenital cardiac surgery, was still uncertain in small infants when its prophylactic use was suspended for safety reasons. The aim of this study is to describe associations between the prophylactic use of high‐dose aprotinin, the need for blood product transfusions, and short‐term outcome in neonates and infants with cardiac surgery.

Relative Low Flow Extra Corporeal Co2-Removal in Ards Patients: A Pilot Study

Mechanical ventilation (MV) of patients with Acute Respiratory Distress Syndrome (ARDS) should be performed with a lung protective strategy, since this is associated with better clinical outcomes. Lung protective MV contains the lowering of the plateau pressure (PPLAT) and the tidal volume (VT). Physicians choice for lung protective MV can be hindered by the consequence of decreased CO2 clearance, i.e. respiratory acidosis. Veno-venous extracorporeal CO2-removal (ECCO2-R) is a recent therapy allowing extracorporeal CO2 clearance and normalisation of pH.